Commentary: Tele-ICU Development and Application

JHN Journal, Feb 2017

BACKGROUND The demand for intensivist care aimed at the critically ill in ICUs is ever-growing as life expectancy increases, creating a tension in supply and demand.1 With the aging population rapidly expanding and there being a lack of new board-certified critical care specialists, it is predicted that there will be a shortage of staff in the intensive care unit.2,3 Part of this scarcity can be attributed to the aging nurse population as the number of RNs under the age of 30 has seen a major regression.4 Also, lack of physicians in rural areas has caused a decline in the quality of health care offered to patients who reside in these areas. It is estimated that 20% of US citizens live in rural areas and only 9% of its physicians practice there.5 To counter this decline in specialists and lack of access to those who live in rural areas, the industry has turned to alternative forms of care, much of the substitute being technology based; also known as telemedicine.6

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Commentary: Tele-ICU Development and Application

COMMENTARY: Tele-ICU Development and Application Annalise DeJesus 0 M. Kamran Athar 0 0 Department of Neurological Surgery, Thomas Jefferson University , Philadelphia, PA , USA The demand for intensivist care aimed at the critically ill in ICUs is ever-growing as life expectancy increases, creating a tension in supply and demand.1 With the aging population rapidly expanding and there being a lack of new board-certified critical care specialists, it is predicted that there will be a shortage of staff in the intensive care unit.2,3 Part of this scarcity can be attributed to the aging nurse population as the number of RNs under the age of 30 has seen a major regression.4 Also, lack of physicians in rural areas has caused a decline in the quality of health care offered to patients who reside in these areas. It is estimated that 20% of US citizens live in rural areas and only 9% of its physicians practice there.5 To counter this decline in specialists and lack of access to those who live in rural areas, the industry has turned to alternative forms of care, much of the substitute being technology based; also known as telemedicine.6 ROBOTIC TELEPRESENCE BACKGROUND APPLICATION Telemedicine is defined as the exchange of medical information from one site to another through electronic communications, to improve a patient’s clinical health status.7 This new technology allows organizations to transcend past the boundaries of geographic space and time to offer their services.8 There are a variety of applications as telemedicine is a general term, such applications include: two-way video, email, smartphones, remote monitoring, and robotic presence.7,9 The idea of telemedicine can be traced back to as early as the 1800s when electronics such as the telegraph became available for public use.10 When the telephone was invented in the early 1900’s, it became a quick way for physicians to communicate and is still one of the primary forms of communication in the medical world.11 Modern telemedicine systems, in particular remote-monitoring, can be linked to the National Aeronautic and Space Administration (NASA). The respiratory and circulatory function of the human body when in space was questioned during the early times of manned flight. This prompted the development of the Integrated Medical and Behavioral Laboratories and Measurement Systems (IMBLMS) program in 1964. The IMBLMS expanded upon the measurements system that allowed the biometrics of the astronauts to be monitored during critical times.12 The updated technology aided in the case of emergencies when return to earth wasn’t possible. Not only would biometric data be transmitted to the base, but also guided medical treatment by non-physicians when made available. In medical emergencies mid-flight, only the crewmembers were there to help.13 Around the time of the development of remote-monitoring, the development of two-way video communication emerged. A clinical trial for two-way video took place at the University of Nebraska in the early 1960’s when neurological examinations were transmitted across campus to medical students. Next, group consultation was tested and a telemedicine link was set up between the University and Norfolk State Hospital. Speech therapy, neurological-examinations, diagnoses and consultations were successfully provided.14,15 Within recent years the use of robotic telepresence has seen major growth. Robotic telepresence is the incorporation of video conferencing equipment onto mobile robotic devices, which is then controlled from a remote location, including mobile devices like iPad and smart phones.16 This new technology allows for more timely responses from specialists, which has been seen in other tele-ICU applications. The primary headquarters for the robotics is InTouch Health located in California, which is integrated with Global Care Quest. A study done at UCLA from 2005-2006 set out to test the effectiveness of telerobotics in the ICU. Observations were made during nighttime rounds where physicians and attendants would determine if any patients seemed unstable. Physicians, via the robotic presence, then monitored these patients determined to be unstable. From a remote location the physician could control the movement of the robot to examine patients as well as speak to them, asking them to perform certain tasks as part of the neurological examination. The results showed that the length of stay for patients admitted into the ICU was reduced which in turn also cut costs for the ICU by $1.1 million during the year the trial took place.17 TELEMEDICINE IN THE ICU A clinical trial conducted by Grundy et. al.16 published in 1977 reveals the success telemedicine has on patients in critical care who have limited access to specialists. The project set up took place between a large university hospital and a small inner-city hospital. An intensivist provided consultation from the remote hospital via a two-way audiovisual link and camera. The results showed that telemedicine could provide a valuable link between smaller and larger hospitals to deliver better quality care. The program was however shut down due to funding costs. A similar study conducted by Breslow et. al.17 yielded positive results as well. From the years 1999-2001, 2,140 patients in two adult ICUs of a large tertiary care hospital were provided with a supplemental remote care program. It was concluded that the additional supplement improved clinical outcomes and hospital financial performance. It was then concluded that telemedicine may be an alternative to provide quality care with fewer intensivists needed on-site. TELENEURO-ICU/ TELESTROKE The development of teleneuro and telestroke ICU is still fairly new. The idea behind teleneuro-ICU is to optimize the diagnosis and treatment of neurological emergencies. Most neurological emergencies such as acute ischemic strokes are extremely time sensitive and require specialist diagnosis.18 Ischemic stroke in particular is a major problem that has low treatment rates. The conflict between distribution of specialists and incidence of stroke presentation greatly affects the accessibility to timely and appropriate care.19 In a study done in Burgundy, France the safety and effectiveness of telemedicine for acute ischemic stroke was evaluated. The outcomes measured at 3 months by a modified Ranking scale score and case fatality concluded that the use of regional telemedicine was effective in the treatment and management of acute ischemic stroke. It was then determined that the percentage of patients who benefit from thrombolysis will increase.20 THE FUTURE OF TELEMEDICINE IN NEURO ICUS The future for teleneuro and telestroke is promising as the application and promises of telemedicine in the neurocritical-ICU increase as a whole. Telestroke has the potential to enhance stroke education through patient and health-care professional interaction. Not only is education enhanced from this aspect, but also through the ability to use telecommunication-links to provide classes on interactive stroke care and prevention to locations that are limited otherwise.21 Economically, telestroke has been shown to be cost-effective from both societal and hospital perspective. The drawbacks to telestroke use come from the need for state licensing and credentialing of physicians. Also from a technical aspect, telestroke and telemedicine in general require a minimum network bandwidth; some regions don’t have access to this yet. These issues can however be mitigated as technology expands to the more rural regions and licensing becomes easier to acquire as the application of telemedicine and telestroke continues to expand.22 7. American Telemedicine Association 1. Brewick , DM , Nolan TW , Whittington J. The triple aim: Care, Health, and cost . Health Aff (Milwod) 2008 ; 27 : 759 - 769 . 2. Krell K. Critical care workforce . Crit Care Med 2008 ; 36 : 1350 - 1353 3. Halpner NA , Pastores SM : Critical care medicine in the United Dtates 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs . Crit Care Med 2010 , 38 : 65 - 71 4. Buerhaus , P.I. , & Staiger , D. O. , & Auerbach , D. I. ( 2000 ). Why are shortages of hospital RNs concentrated in specialty care units? Nursing Economics , 18 , 111 - 116 . 5. Bureau of Health Professions, Health Resources and Services Administration . Rural health professions facts: supply and distribution of health professions in rural America. Rockville, MD. Bureau of Health Resources and Services Administration , 1992 . 6. Doarn CR , Merrell RC . A roadmap for telemedicine: barriers yet to overcome . Telemed J E Health . 2008 ; 14 ( 9 ): 861 - 2 . Doi: 10 .1089/ tmj. 2008 . 8479 . (PubMed) (Cross Ref) 8. Turner JW , Thomas RJ , Reinsch NL . Willingness to try a new communication technology: Perpetual factors and task situations in a health care context . Journal of Business Communication . 2004 ; 41 ( 1 ): 5 - 26 . 9. Becevic , M. ; Clarke , M.A. ; Alnijoumi , M.M. ; Sohal , H.S. ; Boren , S.A. ; Kim , M.S. ; Mutrux , E.R. Robotic telepresence in a medical intensive care unit - clinical perceptions . Perspective in Health Information Management , 2015 ; 12 (Summer) 10. Turner JW . Telemedicine: Expanding healthcare into virtual environments . In: Thompson TL , Dorsey AM , Miller KI , Parrott R , editors. Handbook of health communication . 2003 . pp. 515 - 535 . 11. Zundel KM . Telemedicine: History, Applications, and Impact on Librarianship. Bulletin of the Medical Library Association . 1996 ; 84 ( 1 ): 71 - 79 . [PubMed] 12. Simpson , A. T. ( 2013 , August 16 ). Retrieved June 16 , 2016 , from http://www.nasa.gov/content/abrief -history-of-nasa-s-contributions-to-telemedicine/#_ednref4 13. Lockheed Missiles and Space Company, “STARPAHC Systems Report vol. 1 ” 30 October 1977 , copy in “Telemedicine STARPAHC” file, NASA Historical Reference Collection, History Division , NASA Headquarters, Washington, DC. 2- 1 . 14. Institute of Medicine (US) Committee on Evaluating Clinical Applications of Telemedicine; Field MJ, editor . 15. Washington (DC): National Academies Press (US); 1996 . 16. Wittson CL , Benschoter RA . Two-Way Television: Helping the Medical Center Reach Out . American Journal of Psychiatry . 1972 ; 129 ( 5 ): 136 - 139 . 17. Mirna Becevic , PhD, MHA; Martina A. Clarke , MS; Mohammed M. Alnijoumi, MD; Harjyot S. Sohal, MD; Suzanne A. Boren, PhD , MHA; Min S. Kim, PhD; and Rachel Mutrux . “ Robotic Telepresence in a Medical Intensive Care Unit-Clinicians' Perceptions.” Perspectives in Health Information Management ( Summer 2015 ): 1 - 9 . 18. Vespa , P. ( 2005 ). Robotic telepresence in the intensive care unit . Crit Care Clin , 9 ( 4 ), 319 - 320 . doi: 10 .1186/cc3743 19. Grundy BL , Crawford P , Jones PK , et al. Telemedicine in critical care: an experiment in health care delivery . JACEP . 1977 ; 6 ( 10 ): 439 - 444 . 20. Breslow MJ , Rosenfeld BA , Doerfler M , Burke G , Yates G , Stone DJ , Tomaszewicz P , Hochman R , Plocher DW : Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing . Crit Care Med 2004 , 32 : 31 - 38 21. Klein , K. E. ; Rasmussen , P. A. ; Winners , S. L. ; Frontera , J. A. ( 2015 ). Teleneurocritical care and telestroke . Crit Care Clin , 31 ( 2 ), 197 - 224 . doi: 10 .1016/j.ccc. 2014 . 12 .002 22. Akbik , F. ; Hirsch , J. A. ; Chandra , R. V. ; Frei , D. ; Patel , A. B. ; Rabinov , J. D. ; Rost , N. ; Schwamm , L. H. ; Leslie-Mazwi , T. M. ( 2016 ). Telestroke-the promise and the challenge . Part one: growth and current practice . J Neurointerv Surg. doi: 10 .1136/neurintsurg-2016 -012291 23. Legris , N.; Hervieu-Bègue , M. ; Daubail , B. ; Daumas , A. ; Delpont , B. ; Osseby , G. V. ; Rouaud , O. ; Giroud , M. ; Béjot , Y. ( 2016 ). Telemedicine for the acute management of stroke in Burgundy, France: an evaluation of effectiveness and safety . Eur J Neurol. doi: 10 .1111/ene.13054 24. Levine , S. R. ; Gorman, M. ( 1999 ). “Telestroke”: the application of telemedicine for stroke . Stroke , 30 ( 2 ), 464 - 469 . 25. Hess , D. C. ; Audebert , H. J. ( 2013 ). The history and future of telestroke . Nat Rev Neurol , 9 ( 6 ), 340 - 350 . doi: 10 .1038/nrneurol. 2013 .86


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Annalise DeJesus, M. Kamran MD Athar. Commentary: Tele-ICU Development and Application, JHN Journal, 2017,